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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600586
Report Date: 11/20/2022
Date Signed: 11/20/2022 04:56:27 PM

Document Has Been Signed on 11/20/2022 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KINDWEILER HOMEFACILITY NUMBER:
198600586
ADMINISTRATOR:GAMIO, CLAUDIA V.FACILITY TYPE:
735
ADDRESS:272 EAST 213TH ST.TELEPHONE:
(310) 999-8666
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 3DATE:
11/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Claudia GamioTIME COMPLETED:
04:57 PM
NARRATIVE
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On 11/20/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with licensee and administrator Claudia Gamio. LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory adults ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and a garage.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured 105.9. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was complete. The facility has a working landline telephone. The facility staff all have CPR/First Aid certificates training that are current.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/20/2022 04:56 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/20/2022 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section. LPA observed stove and overhead microwave oven uncleaned and not sanitary. This violaton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 80076 regulations and comply. The administrator will ensure that facility is cleaned and sanitary at all times. Proof of correction must be sent to LPA by POC due date: 12/12/22.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. LPA identified the last fire drill conducted was August 2021. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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The Licensee/Administrator shall review the Health and Safety Section 1565 regulations and comply. The administrator will ensure to conduct a Fire Drill and must do drills ongoing basis. Proof of correction must be sent to LPA by POC due date: 12/12/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


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Document Has Been Signed on 11/20/2022 04:56 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/20/2022 at 03:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation)(record review), the licensee did not comply with the section cited above. Client #3 (C3) had medication error and was not provided prescibe meds timely. This violaton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 80075 regulations and comply. The administrator will hold a medication training with all staff and must have written proof of completion of training by the POC due date: 12/12/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


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Document Has Been Signed on 11/20/2022 04:56 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/20/2022 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(1-5)
85068.4 Acceptance and Retention Limitations (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: 1) Completed Functional Capabilities Assessment, required by Section 80069.2...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, interview and record review, Client #2-#3 (C2) and (C3) are over 60 years old, The facility does not have approved age exceptions for any of the clients. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 85068.4 regulations and comply. The administrator shall send a request for age exceptions for clients 60 years of age and over by the POC due date: 12/12/22.
Type B
Section Cited
CCR
85064.2(h)(1)
(h) Certificates shall be valid for a period of two (2) years and expire on either the anniversary date of initial issuance or on the individual's birthday during the second calendar year following certification. (1) The certificate holder shall make an irrevocable election to have his or her recertification date for any subsequent recertification either on the date two years from the date of issuance of the certificate or on the individual's birthday during the second calendar year following certification.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above. LPA identified administrator and assistant administrator do not have valid administrator's certificate on file with CCLD. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 85064.2 regulations and comply. The administrator will apply to be recertified for administrator's certification immediately. A proof of must be sent by the POC due date: 12/12/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586
VISIT DATE: 11/20/2022
NARRATIVE
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. A review of staff and client's vaccinations are maintained in order. The facility has an approved Mitigation Plan on file with CCLD.

DEFICIENCIES:
During the inspection, LPA observed the facility has not conducted an emergency disaster drill in the past six (6) months. LPA observed the stove top and oven unclean and not sanitary. LPA identify medication error for client #3 (C3) dated 11/20/22. LPA observed client #2-#3 (C2-C3) both over 60 years of age and the facility failed to submit an Age Exemption to CCLD. LPA identified administrator and assistant administrator both had expired administrators certificates. These deficiencies are a violation of Title 22, Division 6 Chapter 1.

Deficiencies cited on LIC 809D.

An exit interview was conducted and a copy of this report and Appeal Rights were provided to Claudia Gamio.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2022
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